Rooting an Error Review Process in Just Culture: Lessons Learned

Abstract

Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. We had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, we committed ourselves to trying something genuinely different—even perhaps disruptive—that might actually shift our stagnant metrics. Our novel, multifaceted program, implemented over a two-year period, yielded a 13% increase in staff rating scores that we have been able to sustain over the subsequent two-year period. The design and rollout of our program was neither simple nor smooth, but it has taught us valuable lessons about realistic, operational implementation of principles of psychological safety in a large and complex clinical organization. In this paper, we describe our program and the lessons learned in the journey from idea inception to post-implementation.